Date of Meeting: Ratified Date: 23/08/2006. Does this document meet with the Race Relation Amendment Act (2000) Not Applicable

Transcription

1 Document Type: POLICY Title: Hand Hygiene Scope: Trust Wide Unique Identifier: CORP/POL/056 Version Number: 1 Status: Ratified Classification: Organisational Author/Originator and Title: Johanne Lickiss Clinical Infection Control Nurse Replaces: All pevious Hand Hygiene Policy Responsibility: Control of Infection Clinical Governance Directorate Description of amendments: Throughout the Document comply with Trust format Name of Committee/Directorate/ Working Group: Clinical Governance Team Management Meeting Date of Meeting: 19/07/2006 Risk Assessment: Not Applicable Validated by: N Gavin Chairman s Action for HIC Committee Clinical Governance Committee Chairman s Action Validation Date: 11/10/ /08/2006 Ratified by: Trust Board Review Dates: Review dates may alter if any significant changes are mad Ratified Date: 23/08/2006 Date of Issue: 23/08/2006 Review Date: 01/05/ Does this document meet with the Race Relation Amendment Act (2000) Not Applicable

2 1 PURPOSE. The purpose of this policy is to ensure that all staff follow national guidelines on hand hygiene. 2 SCOPE. All Healthcare workers employed by the Trust (BFWH). 3 POLICY 3.1 Introduction The spread of infection via hands is well established. Hand decontamination is one of the most important procedures for preventing the spread of disease. Hands are the principle routes by which cross-infection occurs. Hand hygiene is an infection control practice with a clearly demonstrated efficacy, and remains the cornerstone of efforts to reduce the spread of infection. The current spread of antibiotic resistant organisms can be attributed, at least in part, to a failure by health care professionals to wash their hands either as often or as efficiently as the situation requires. Improved adherence to hand hygiene has been shown to terminate outbreaks in health care facilities, to reduce transmission of anti-microbial resistant organisms (e.g. Methicillin Resistant Staphylococcus Aureus) and reduce overall infection rates. All health care workers must attend hand hygiene training sessions through annual updates. These are provided through Mandatory Training at the Clinical Skills Lab and through Clinical Updates. Non-attendees will be followed up by the Department Manager/Lead. Hand hygiene will be monitored through audit and spot checks using the hand hygiene light source box by the Infection Control Nurses. Hand hygiene champions will conduct audits of hand hygiene on ward/department areas. The awareness of hand hygiene will be raised amongst staff, patients and visitors through the Cleanyourhands campaign, posters, hand hygiene leaflets and roadshows. 3.2 Principles of Hand Hygiene Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated. Page 2 of 6

3 Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material must be washed with liquid soap and water. Hands must be decontaminated - if not visibly soiled - with an alcohol-based handrub between caring for different patients and between different care activities for the same patient. Alcohol handrubs take less time to use than traditional hand washing, significantly reducing the number of microorganisms on skin and are fast acting. The use of gloves does not eliminate the need for hand washing. The use of hand hygiene does not eliminate the need for gloves. Before regular hand decontamination begins, all wrist and hand jewellery must be removed. Cuts and abrasions must be covered with waterproof dressings. Fingernails must be kept short and clean. The wearing of any form of nail art by all staff involved in procedures that require a high level of hand hygiene is banned within this Trust. Staff groups that this applies to include all clinical staff, all staff in sterile services (CSSD), all pathology staff and all pharmacy staff. 4 ATTACHMENTS. Appendix 1 References Appendix 2 Definitions 5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION. Held By: Directorate/Department/Author Held in format: Electronic and/or hard copy Database for Policies, Procedures, Protocols and Guidelines Archive/Policy Co-ordinators office 6 LOCATIONS THIS DOCUMENT ISSUED TO. Copy No Location Date Issued 1 Intranet 23/08/2006 Wards and Departments 23/08/ OTHER RELEVANT /ASSOCIATED DOCUMENTS. Procedure No. Corp/Proc/418 PL/184 Title Hand Hygiene Procedure Hand Hygiene Leaflet Page 3 of 6

4 8 AUTHOR/DIRECTORATE MANAGER APPROVAL. Issued By Mrs J Lickiss Checked By M Aubrey Job Title Clinical Nurse Specialist Job Title Head of Clinical Governance Signature Signature Date July 2006 Date July 2006 Page 4 of 6

5 Appendix 1 References Guidelines for Hand Hygiene. ICNA & Deb Ltd 1999 Pratt RJ, Pellowe C, Loveday HP, et al. The epic project: Developing National Evidencebased Guidelines for Preventing Healthcare Associated Infections. Journal of Hospital Infection 2001; supplement Infection Control: Prevention of healthcare-associated infection in primary and community care. National Institute for Clinical Excellence 2003 Evidence Based Practice in Infection Cotnrol project guidelines (EPIC) National Institute for Clinical Effectiveness Guidelines (NICE) Infection Control Nurses Association - Guidance Page 5 of 6

6 Appendix 2 Definition Hand hygiene: This is an infection control procedure with a clearly demonstrated efficacy and remains the cornerstone of efforts to reduce the spread of infection Page 6 of 6