WAHT-INF-002 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet HAND HYGIENE POLICY

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1 HAND HYGIENE POLICY This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION The Health Act (Department of Health 2008) requires NHS organisations to have up to date policies and procedures, which minimise the risk of healthcare associated infection (HCAI). This includes evidence-based hand hygiene guidelines that promote timely and effective hand decontamination. Hand hygiene forms part of Standard Precautions, consequently this policy should be read in conjunction with other key policy documents located in the Trust Infection Control Policies. THIS POLICY IS FOR USE BY THE FOLLOWING STAFF GROUPS: All trust employees and staff working for and on behalf of the Trust including contractors, voluntary workers, students, and locum and agency staff. Gillian Byrne Policy Lead Approved by Trust Infection Prevention & Control Committee on: Senior Infection Prevention & Control Nurse 22 nd June 2015 This policy should not be used after end of: 22 nd July 2017 Key amendments to this policy: Date Amendment By: July 2010 Addition of paragraphs: Gillian Byrne 4 Responsibilities of all staff 15 Equality Assessment 16 Financial Assessment Addition of Appendices: Your 5 Moments of Hand Hygiene Hand Cleaning Techniques including use of Alcohol Sanitising Gel Hand Hygiene Audit Tool Hand Hygiene Competence Tool October 2011 Addition of new Hand Hygiene Audit Tool Appendix 5 H Gentry Extension of policy expiry by 12 months January 2013 Additions to audit section for NHSLA A Dyas March 2015 Addition of paragraphs: Gillian Byrne 7 When to perform Hand Hygiene 11 Use of a Clinical Hand Wash Basin/Sink Addition of Appendices Updated version from WHO 5 Moments of Hand Hygiene Updated Hand Hygiene Observation Tool (HHOT) WAHT-INF-002 Page 1 of 23 Version 4

2 INDEX PAGE 1 HAND HYGIENE 2 AIMS AND OBJECTIVES 3 INTRODUCTION 4 RESPONSIBILITIES OF ALL STAFF 5 MICROBIOLOGY OF THE SKIN 5A Resident Flora 5B Transient Flora 6 WHY PERFORM HAND HYGIENE? 7 WHEN TO PERFORM HAND HYGIENE 8 WHAT SOLUTION SHOULD BE USED TO PERFORM HAND HYGIENE? 9 HOW LONG SHOULD IT TAKE TO PERFORM HAND HYGIENE? 10 PREPARATION FOR HAND HYGIENE 11 HOW TO PERFORM HAND HYGIENE 12 CARE OF HANDS 13 CLEANYOURHANDS CAMPAIGN 14 HAND HYGIENE GUIDELINES KEY POINTS 15 TRAINING AND AUDIT 16 EQUALITY ASSESSMENT 17 FINANCIAL ASSESSMENT 18 REFERENCES 19 CONTRIBUTION LIST APPENDIX 1: APPENDIX 2: APPENDIX 3: APPENDIX 4: APPENDIX 5: APPENDIX 6: Your 5 Moments of Hand Hygiene WHO Patient s Environment Hand Hygiene Washing step by step images Hand Hygiene alcohol Scrub Technique Hand Cleaning Technique step by step images Hand Hygiene Observation tool (HHOT) Hand Hygiene Competence form WAHT-INF-002 Page 2 of 23 Version 4

3 1 HAND HYGIENE Hand hygiene is a term that incorporates the decontamination of the hands by methods including hand washing, surgical scrub and the use of alcohol rubs and gels. (Boyce and Pittet 2002). 2 AIM AND OBJECTIVES Aim: To promote hand hygiene as evidence-based practice and to define responsibilities and actions required for compliance with good hand hygiene practice throughout the organisation. Objectives: To identify the importance of hand hygiene in the prevention of healthcare associated infections (HCAI) To describe the key elements of good hand hygiene practice To identify strategies to implement the policy and improve compliance with good hand hygiene practice 3 INTRODUCTION Why Clean Your Hands? The spread of infection via hands is well established (Ayliffe et al 1992). HCAIs are a major problem in modern health care and a cause of concern to health care workers and the general public (Masterton and Teare 2001). Hands are the principle route by which cross infection occurs (Elliot 1992). Consequently hand hygiene is considered the simplest and most cost effective measure for reducing HCAI (Reybrouck 1983). Hand decontamination has a dual role, to protect both the patient and the healthcare worker from acquiring micro-organisms, which may cause them harm. It is therefore an important component of risk management and clinical governance. 4 RESPONSIBILITIES OF ALL STAFF The responsibilities of all staff with respect to this policy are described in the Management of Infection Prevention and Control Policy WAHT-CG-043. In particular, it is the responsibility of all staff in all departments to follow this policy in their personal practice, and it is the responsibility of all managers to ensure that all their staff have been trained in the operation of this policy, and that the necessary equipment to enable the policy to be followed completely is always available in their departments. Anyone observing any breaches of this policy also has a responsibility to report to the appropriate manager, who must ensure that correct practice is observed by all their staff. 5 MICROBIOLOGY OF THE SKIN 5A Resident Flora: Resident bacteria form part of the body s normal defence mechanisms, 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 where there is a breach in the integrity of the skin, resident flora may enter deep tissues and cause infections. 5B Transient Flora: WAHT-INF-002 Page 3 of 23 Version 4

4 These organisms are acquired by touch for example from direct contact, (touching patients), or indirect contact (touching laundry, equipment, contaminated surfaces, etc). They are located superficially on the skin, readily transmitted to the next person/item touched and are responsible for the majority of HCAI s. They are easily removed by applying good hand hygiene techniques. 6 WHY PERFORM HAND HYGIENE? Level 1 Social Hand Hygiene To render the hands physically clean and to remove micro-organisms picked up during activities considered social activities (transient micro-organisms). Level 2 Hygienic Hand Hygiene To remove or destroy transient micro-organisms and to provide residual effect during times when hygiene is particularly important in protecting yourself and others (reduces numbers of resident micro-organisms). Level 3 Surgical scrub To remove or destroy transient micro-organisms and to reduce substantially the numbers of those microorganisms which normally live on the skin (resident microorganisms) during times when surgical procedures are being carried out. 7 WHEN TO PERFORM HAND HYGIENE Both the decision to decontaminate hands, and what type of cleaning agent to be used should be based on a risk assessment. This must include the likelihood that microorganisms have been acquired or may be transmitted, whether the hands are visibly soiled, and what procedure is about to take place. The World Health Organisation (WHO) have developed the Five Moments for hand hygiene, defining the key points for healthcare workers to clean their hands. (See Appendix 1) Level 1 Social Hand Hygiene Level 2 Hygienic Hand Hygiene BEFORE BEFORE / BETWEEN BEFORE 1. Commencing / leaving work 1. Aseptic procedures 2. Using a computer keyboard/telephone (in a clinical area) 3. Eating / handling of food/drinks (whether own or patient / clients) 4. Preparing / giving medications 5. Direct patient / client contact where no exposure to blood, other body fluids, or non-intact skin has occurred 2. Touching immunocompromised patients / clients 3. Caring for those with an actual / potential infection 4. Leaving rooms where patients / clients are being cared for in isolation due to potential for spread of infection to others Level 3 Surgical scrub 1. Surgical / invasive procedures NB: See specific policies and procedures on surgical preparation WAHT-INF-002 Page 4 of 23 Version 4

5 Level 1 Social Hand Hygiene AFTER 1. Becoming visibly soiled 2. Visiting the toilet 3. Touching patient / client even where no exposure to blood, other body fluids, or non-intact skin has occurred 4. Using a computer keyboard / telephone (in a clinical area) 5. Handling laundry / equipment / waste 6. Blowing / wiping / touching nose 7. Any touching inanimate objects (eg equipment, items around the patient / client) and the patient / client immediate environment, ie bed space / chair Appendix 1 5 Moments 8. Removing gloves Level 2 Hygienic Hand Hygiene AFTER 1. In contact with blood, other body fluids, excretions, secretions, mucous membranes, non-intact skin, wound dressings, spore forming organisms (suspect and proven) 2. Any Invasive devices including manipulation of the device and or IV line following removal of gloves And social hand hygiene 3. Following administration of medications including intravenous substances Following social hand hygiene and removal of gloves 4. Touching patients / clients being cared for in isolation due to the potential for spread of infection to others Following social hand hygiene and removal of gloves 5. In high risk areas at all times, i.e. (i) Infant nurseries / special care baby units; (ii) Infectious disease units / intensive / critical care / high dependency / therapy units/burns units (iii) Wards / departments / units during outbreaks of infection (iv) Surgical / invasive procedures Level 3 Surgical scrub Even if gloves have been worn hand washing must be performed as per recommendations above as hands may still be contaminated beneath gloves or upon their removal and therefore may pose a risk for transmitting micro-organisms. It should also be noted that hand hygiene may have to be performed between WAHT-INF-002 Page 5 of 23 Version 4

6 tasks on the same patient according to the WHO 5 Moments for Hand Hygiene Appendix 1 WHAT SOLUTION SHOULD BE USED TO PERFORM HAND HYGIENE? Level 1 Social Hand Hygiene Level 2 Hygienic Hand Hygiene Level 3 Surgical scrub Hand washing with foam / liquid soap or decontamination with alcohol based sanitising gel Hand washing with foam / liquid soap followed by alcohol based sanitising gel Hand washing with an approved antiseptic hand cleanser, eg Hibiscrub or 85% alcohol gel a stronger formula is recommended contact Infection Control for details. Topping up of individual bottles that contain solution should never occur as the inside of bottles, even those containing antiseptic solutions, can become a breeding ground for bacteria over time Where infection with Norovirus / Clostridium difficile is suspected or proven it is recommended that hand hygiene is carried out with foam / liquid soap and water followed by alcohol based sanitizing gel (i.e. Level 2) Epic 3 sited that two laboratory studies demonstrated that alcohol based hand gel was not effective in removing C. difficile spores from hands alone (Pratt et al 2013) Any soiling / organic matter can inactivate the activity of alcohol based sanitizing gel and, therefore, hand washing with foam / liquid soap in these circumstances is essential 9 HOW LONG SHOULD IT TAKE TO PERFORM HAND HYGIENE? Level 1 Social Hand Hygiene At least 15 seconds + drying time Level 2 Hygienic Hand Hygiene At least 15 seconds + drying time Level 3 Surgical scrub 2-3 minutes 10 PREPARATION FOR HAND HYGIENE Action Keep fingernails short Do not wear hand or wrist jewellery / wristwatch A plain wedding ring may be worn; this should be able to be moved up the finger to allow cleaning & drying beneath. Do not wear false nails or nail varnish Bare below the elbows practice should be observed by rolling up or wearing short sleeves Rationale Long nails are harder to keep clean and can cause trauma to patient s skin. They can harbour micro-organisms and can reduce the effectiveness of hand hygiene. If worn it must be moved / removed in order to reach the bacteria, which can be harboured underneath it. Can harbour micro-organisms and can reduce compliance with hand hygiene Hand hygiene technique includes the wrists. Long sleeves will prevent the wrists from being properly de-contaminated. WAHT-INF-002 Page 6 of 23 Version 4

7 11 HOW TO PERFORM HAND HYGIENE Correct Hand Hygiene Facilities Access to appropriate hand hygiene facilities, and associated supplies, is essential to ensure that adequate hand hygiene can be performed when indicated It has been shown that inadequate facilities will lead to poor hand hygiene performance. The use of hands free tap systems is crucial in preventing re-contamination of hands following hand hygiene procedures at a sink and should be available as far as possible, particularly where personal care is delivered in clinical settings. These can include: Wrist, elbow or foot taps. Motion sensor controlled taps (for example those that turn on and off when hands are moved in front of a light sensor, no touching of the sink / tap system required). It is preferred that there are no plugs in hand hygiene sinks in order to avoid the filling of sinks with water as this is not an appropriate way to perform hand hygiene. Mixer taps are preferred, to provide the correct temperature of water for performing hand hygiene, as this is an important step in the process. A hand hygiene technique poster should be above every clinical hand wash basin/sink to instruct staff on how they can achieve a satisfactory hand wash for the purposes of de-contaminating their hands Use the clinical hand wash basin/sink only for hand washing this is to ensure best practice is followed to reduce the risk of Pseudomonas aeruginosa which is an opportunistic pathogen often associated in water sources and potential contamination of taps, basins and water systems.(doh 2012) a. Do not dispose of body fluids at the clinical hand-wash-hand-basin use the dirty utility area. b. Do not wash any patient equipment in hand-wash-basins. c. Do not use hand-wash-basins for storing used equipment awaiting decontamination. Foam / Liquid Soap Must be available at all hand washbasins and sinks. Alcohol based Sanitising Gel Near patient alcohol based sanitising gel Use end of bed holders or encourage all clinical staff to carry their own alcohol based sanitising gel (or both!). These holders also fit medical records trolleys and drug trolleys. Wall mounted alcohol based sanitising gel Wall mounted gel should be provided at every clinical sink, outside all isolation rooms, at the entrance to and at strategic points on the wall in wards and departments. Automatic dispensers are fitted outside all main ward and department areas. Please contact Infection Prevention and Control if additional dispensers are required. WAHT-INF-002 Page 7 of 23 Version 4

8 Emollients Use the "Hand Medic" hand emollient, supplied in black dispensers or individual bottles. See 12 for care of hands. Paper Towels A soft white disposable paper towel must be provided for hand drying in all clinical areas. It is the responsibility of the Housekeeping Services to replace the empty cartridges of gel, soap, hand cream and paper towels and they should ensure that they are replaced immediately; they should also be cleaned on a regular basis to ensure that the nozzles of the dispenser is not blocked and if drip trays are in use should be clean and free from grime and dust. If they find dispensers broken or not working they must raise this with the Maintenance Department to ensure they are promptly replaced or fixed. Waste Bins The appropriate waste stream bin should be hands free and be operated by a foot pedal. Waste receptacles should be at all hand wash sinks or close at hand for disposal of used paper towels. Used paper towels can be discarded into black bags unless used in isolation rooms, when they should be disposed into clinical waste bags. Social and Hand Hygiene Washing Use foam / liquid soap and follow the step-by-step image (Appendix 2). Surgical Scrub Use the appropriate anti-microbial soap and follow the hygienic hand wash process for 2-3 minutes, ensuring all areas of hands and forearms are covered (Appendix 3 Scrub Technique). Single use sterile nailbrushes may be used for the first application of the day (continual use damages the skin which will encourage colonisation with micro-organisms). Between cases, a more effective method is the application of an alcohol sanitising gel. A stronger formula than the ward version is recommended, this has an alcohol content of 85%. The aim of reducing micro-organisms on the operator s hands is to reduce the risk of wound contamination following glove perforation during a surgical procedure. Alcohol based Sanitising Gel The hands should be rubbed until dry. Follow images on Appendix 4. Hand Drying Hand drying has been shown to be a critical factor in the hand hygiene process. In particular, the removal of any remaining residual moisture that may facilitate transmission of micro-organisms is important. Hands which are not dried properly can become dry and cracked, leading to an increased risk of harbouring micro-organisms on the hands that might be transmitted to others. To reduce skin damage during drying patting / blotting rather than rubbing is recommended. Hand Drying Technique Once the taps have been turned off using a hands free technique use clean, disposable paper towels to dry each area of the hand thoroughly. This should be done by drying each part of the hand remembering all of the steps included in the hand washing process. The disposable towels should be placed immediately into an appropriate waste receptacle, WAHT-INF-002 Page 8 of 23 Version 4

9 avoiding recontamination of the hands by using the foot-operated pedal and correct waste stream bin. Drying the hands using a downward motion is recommended following surgical scrub, (i.e. towards the elbow). 12 CARE OF HANDS Why consider hand care? To protect the skin on hands from drying and cracking, where bacteria may be present and to protect broken areas from becoming contaminated, particularly when exposed to blood and body fluids. Hand emollient can be applied to care for the skin on hands, however only individual bottles of hand emollient or Hand Medic from wall-mounted dispensers should be used. Creams used should not affect the action of hand cleaning solutions being used or the integrity of gloves; the Hand Medic supplied by the Trust is compatible with the soap and alcohol based gel also supplied. Communal tubs of hand cream must not be used as these may become contaminated with bacteria. It is important that all staff report any skin conditions to the trust Occupational Health department or their GP in order that the appropriate skin care and necessary advice can be given, reducing the risk of resident micro-organisms being transmitted while providing care for others. All cuts and abrasions should be covered with a waterproof dressing. 13 CLEANYOURHANDS CAMPAIGN About the Clean your hands Campaign The National Patient Safety Agency (NPSA) developed a multi faceted campaign to help the NHS in England and Wales to improve hand hygiene within healthcare settings. The campaigns main aim was preventing healthcare associated infections (HCAI) by improving hand hygiene at the point of patient / service user care. Evidence has shown that if we can improve staff hand hygiene at this point, we can help prevent HCAI. The Clean your hands campaign has been implemented within Worcestershire Acute Hospitals NHS Trust to improve the quality of clinical care, and to improve hand hygiene compliance in all wards and departments where clinical care is provided. The campaign was first launched with the publication of the NPSA Patient Safety Alert in September 2004, which instructed acute NHS trusts to provide alcohol handrub at the point of care and invited them to participate in the Clean your hands campaign. Since then the campaign has been extended to NHS primary care, ambulance, mental health and care trusts and the NPSA Patient Safety Alert has been updated and reissued (September 2008) to all trusts. Through the campaign, Infection Prevention and Control teams were supported to raise awareness and engage staff locally this is still the case at the WHAT and the trust continue to strive to embed and engage all HCW s to practice hand hygiene at the point of patient care. Key areas of the campaign: Alcohol based sanitising hand gel to be provided at each bed space and at the entrance to all hospital wards and departments. WAHT-INF-002 Page 9 of 23 Version 4

10 All healthcare workers (HCW) to increase their awareness of the importance of hand hygiene Patient and public to participate in the campaign. Staff to be approachable, giving confidence to all patients so they feel that it is acceptable to ask, and expect hand hygiene from all healthcare workers. Each clinical area must be undertaking weekly observational audits using the Hand Hygiene Observational Tool (HHOT) Fuller et al (2007). This enables hand hygiene compliance to be monitored and the results fedback to staff and entered on the Trust s balanced scorecard. It is hoped that this together with the Saving Lives Campaign (DH 2006) will be embedded in clinical governance strategy and encourage HCWs to increase compliance with the Hand Hygiene Policy. (Please see Appendix 5) Patient and Visitors Involvement All staff must ensure relatives and visitors are encouraged to decontaminate their hands when entering and leaving a ward or department. This can be achieved by using the alcohol based sanitising hand gel at the entrance to wards and departments. Staff must ensure that visitors are advised of the need to wash their hands in addition to using the alcohol based sanitising gel when visiting patients with suspected or proven Clostridium difficile infection or Norovirus. Hand wash stations and appropriate signage will be available in areas where hospital wards / departments have been closed due to an outbreak of Norovirus. When admitting patients, staff should ensure that patients and relatives are informed of the campaign and what they can do to help reduce possible contamination whilst in hospital. Staff must ensure that patient and relative information is freely available in wards and departments to encourage hand hygiene compliance. Patients must be offered the opportunity to decontaminate their hands after toileting, before consumption of food or drink and before and after contact with susceptible sites, (eg line insertion sites, wounds or urinary catheters). Patients with invasive devices in-situ should be encouraged to clean hands frequently and be advised not to touch these sites whilst the devices are in place. Staff Champions The importance of staff champions or role models in hand hygiene is critical to ensure local ownership of the Cleanyourhands campaign; the Chief Executive and the Director of Infection Prevention and Control (DIPC) are advocates of the campaign and take an active part in ensuring compliance is met by all healthcare workers. Within the Trust staff champions are expected to lead by example by: Encouraging junior members of their team to use the alcohol based sanitising gel during patient care activities. Demonstrating and performing the highest standards of hand cleaning (washing or the use of alcohol based sanitising hand gel) particularly when moving from one patient to another during ward rounds and clinic appointments within the outpatient setting. Encourage all staff to follow the 5 moments of hand hygiene as laid down by the WHO. Full details of the campaign are available on the Trust Infection Prevention and Control Intranet site. Staff champions can be identified and seen on the Bare below the Elbows posters in all clinical areas. WAHT-INF-002 Page 10 of 23 Version 4

11 14 HAND HYGIENE GUIDELINES KEY POINTS Alcohol based sanitising hand rub solution / gel rubbed to dryness following routine hand washing will remove 99% of transient microorganisms and will have an effect on the resident normal flora of the skin. Foam / liquid soap and water are normally effective for social hand washing and will remove 90-95% of transient microorganisms acquired during normal patient contact. All hand and wrist jewellery including wristwatches must not be worn when working in a clinical area as it inhibits and reduces the practice of thorough hand washing. Patients may also incur scratches to their skin caused by jewellery. All clinical staff must comply with Bare below the Elbows policy (DH 2007) Always wash hands after the removal of gloves. Dispose of gloves directly into the correct waste stream bin using the foot operated pedal DO NOT remove gloves over a patient DO USE paper towels to pat dry your hands following washing DO NOT open waste bins with your hands, always use the foot operated pedal DO Cover cuts and abrasions with a waterproof plaster / dressing DO inform Occupational Health Department if hands become sore red or chaffed DO NOT wear nail varnish (including clear) Do NOT wear artificial or gel nails Hand hygiene is still the most important infection prevention & control practice that healthcare workers can adopt with a clearly demonstrated efficacy and remains the cornerstone of efforts to reduce the spread of infection (Pratt et al 2000). Non Compliance with Policy Staff should be reminded that they must comply with this policy. Names of staff who continue to ignore the policy will be noted recorded and escalated to the relevant senior personnel, for example matron for nursing staff, Clinical Director and Medical Director for Medical staff. 15 TRAINING AND AUDIT Hand hygiene training will be delivered to all relevant staff groups in accordance with the Trust s mandatory training programme and training needs analysis. The Training Department will report on numbers of staff trained to the Trustwide Infection Prevention and Control Committee (TIPCC). It is the responsibility of individual managers to ensure that their staff are adequately trained. This is in accordance with the Trust s Training Policy. The audit of practice on wards / departments will be carried out by Infection Control Nurse / Link Staff using the Department of Health Infection Control audit toolkit; at the present time this is carried out weekly and reported to TIPCC in the balanced scorecard data.. Hand hygiene is also monitored by the IPCT using the HHOT, and will be reported to TIPCC by the lead nurse, IPC, when available. Hand hygiene compliance / competence will be carried out by the Infection Prevention and Control Link Nurses monthly. All staff in clinical areas should hold a valid in date HH WAHT-INF-002 Page 11 of 23 Version 4

12 competence they should have this repeated every 2 years. The results are reported to the IPCT, and included in the monthly lead nurse report to TIPCC. 16 EQUALITY ASSESSMENT The contents of this policy have no adverse effect on equity and diversity. Questions relating to religious practice and worn items and the implementation of this and the trust uniform policy should be referred to DH guidance on uniform and workwear, published March 2010 (see references). 17 FINANCIAL ASSESSMENT The Board accepts its responsibility to meet the criteria of the Hygiene Code in both the provision of hand washing materials and other resource that may be required in response to an outbreak so as to minimise the risk from Healthcare Associated Infection. There are no new costs associated with the implementation of this policy. WAHT-INF-002 Page 12 of 23 Version 4

13 18 REFERENCES Ayliffe GAJ, Lowbury EJL, et al. (1992). Control of Hospital Infection A Practical Handbook. 3 rd edition, London. Chapman and Hall Medical. Boyce J, and Pittet D (2002). Guideline for hand hygiene in Health-Care Settings Recommendations of the healthcare Infection Control Advisory Committee MMWR 51: 1-44 Department of Health (2006) Saving Lives: a delivery programme to reduce healthcare associated infections including MRSA. Dept of Health. London Department of Health, Sept Uniforms and workwear: an evidence base for developing local policy. Available from URL: Department of Health (2008). The Health Act 2006: Code of Practice for the Prevention and Control of Health Care Associated Infections. Revised in January ce/dh_ Department of Health (2012) Water Sources and potential Pseudomonas aeruginosa contamination of taps and water systems Advice for augmented care units. Elliott PRA, (1992). Handwashing: A process of judgement and effective decision-making. Professional Nurse 2: Fuller C, McAteer, Slade R, Cookson B, Michie S, Stone S, (2007) Short Summary of Hand Hygiene Observational Tool (HHOT). Health Protection Scotland (2007) and Procedure. Accessed 28th March 2008 H.P. Loveday J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tingle, a. Bak, J. Browne, J. Priesto, M. Wilcox (2013) National evidence-based guidelines for preventing hospital-acquired infections in NHS Hospitals in England.(Epic 3) Masterton RG and Teare EL. (2001) Clinical governance and infection control in the United Kingdom. Journal of Hospital Infection 47: National Patient Safety Agency. (2004) Cleanyourhands campaign Pittett D. (2001) Improving Adherence to Hand Hygiene Practice: A multidisciplinary Approach. Emerging Infectious Disease. 7: 2; March-April Pratt RJ, Pellow C, Loveday HP, Robinson N, Smith GW and the EPIC Guidelines Development Team (2000). National evidence-based guidelines for preventing hospitalacquired infections: Standard Principles: Thames Valley University. WAHT-INF-002 Page 13 of 23 Version 4

14 Reybrouck G. (1983) The role of hands in the spread of nosocomial infections. Journal of Hospital Infection. 4: Uniforms and workwear; guidance on uniform and workwear policies for NHS employers DH_ published March 210 Water Systems Health Technical Memorandum Addendum Pseudomonas aeruginosa advice for augmented care units DH, Estates & facilities published March 2013 WAHT-INF-002 Page 14 of 23 Version 4

15 19 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Gillian Byrne Senior Infection Prevention Control Nurse Dr Anne Dyas Consultant Microbiologist / Infection Control Doctor Dr Claire Constantine Consultant Microbiologist / Infection Control Doctor Circulated to the following individuals for comments Name Designation Dr Mary Ashcroft Consultant Microbiologist / Infection Control Doctor Dr Thekli Gee Consultant Microbiologist David Shakespeare Associate Chief Nurse/Associate DIPCC Circulated to the following CDs / Heads of department for comments from their directorates / departments Name Directorate / Department Circulated to the chair of the following committees / groups for comments Name Committee / Group Lindsey Webb Trust Infection Prevention and Control Committee WAHT-INF-002 Page 15 of 23 Version 4

16 APPENDIX 1 FIVE MOMENTS OF HAND HYGIENE WHO PATIENT S ENVIRONMENT WAHT-INF-002 Page 16 of 23 Version 4

17 APPENDIX 2 HAND HYGIENE WASHING STEP BY STEP IMAGES Adapted from the World Health Organisation WAHT-INF-002 Page 17 of 23 Version 4

18 APPENDIX 3 HAND HYGIENE ALCOHOL SCRUB TECHNIQUE WAHT-INF-002 Page 18 of 23 Version 4

19 APPENDIX 3 HAND HYGIENE ALCOHOL SCRUB TECHNIQUE continued WAHT-INF-002 Page 19 of 23 Version 4

20 APPENDIX 4 HAND GEL STEP BY STEP IMAGES WAHT-INF-002 Page 20 of 23 Version 4

21 APPENDIX 5 HAND HYGIENE OBSERVATION TOOL (HHOT) Name of Auditor: Ward:.. Date: Number of staff observed: Number of soap dispensers: Number of hand rub dispensers: Health Care Worker Doctor Opportunity Soap & water Hand rub No Action Bare Below the Elbow Name of Non-Compliant Nurse / Midwife Opportunity Soap & water Hand rub No Action Bare Below the Elbow Name of Non-Compliant Health Care Assistant Before touching a Patient After touching a Patient Before a clean/aseptic procedure After bodily fluid exposure After touching the patient s surroundings Opportunity Soap & water Hand rub No Action Bare Below the Elbow Name of Non-Compliant Housekeeper, Therapies & Ward clerk Opportunity Soap & water Hand rub No Action Bare Below the Elbow WAHT-INF-002 Page 21 of 23 Version 4

22 Name of Non-Compliant Porter Opportunity Soap & water Hand rub No Action Bare Below the Elbow Name of Non-Compliant Numbers of soap + Hand rub behaviours x100 = Overall compliance (%) Action points if applicable: Total hand hygiene Opportunities WAHT-INF-002 Page 22 of 23 Version 4

23 APPENDIX 6 HAND HYGIENE COMPETENCE FORM Hand Hygiene Competence Name: Designation: Ward: Site: ALX / KGH / WRH Knowledge Evidence: The candidate should be able to: 1. Demonstrate knowledge of the hand hygiene policy paying attention to the hand washing guidelines 2. Discuss when it is appropriate to clean hands with alcohol gel or soap/water 3. Discuss different clinical situations when hands would need to be cleaned, paying attention to the role of 5 moments of hand hygiene 4. Demonstrate the 12 step hand washing technique 5. Demonstrate knowledge of skin care Performance Criteria Discuss hand hygiene policy Completed Discuss when to clean hands with hand gel and in what situations Discuss when to wash hands with soap & water and in what situations Discuss 12 step hand washing procedure Candidate washes their hands using the 8 step hand washing procedure Discuss skin care and use of approved emollient Signature of Candidate: Date: Signature of Trainer: Date: WAHT-INF-002 Page 23 of 23 Version 4